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How do I fill this out?
To efficiently fill out the Duke Medicine Adult Proxy form, begin by gathering all required personal information for both the patient and Proxy. Ensure you have the necessary documents that confirm your relationship with the patient. Follow the listed instructions to complete each section accurately.
How to fill out the Duke Medicine Adult Proxy and MyChart Access Request?
1
Gather required personal information for both the patient and the Proxy.
2
Attach necessary legal documents confirming Proxy status.
3
Complete all sections of the form accurately.
4
Sign the form to confirm understanding and agreement.
5
Submit the completed form according to submission guidelines.
Who needs the Duke Medicine Adult Proxy and MyChart Access Request?
1
Family members acting as proxies to manage medical decisions.
2
Legal guardians responsible for the care of incapacitated individuals.
3
Spouses needing access to a partner's medical records.
4
Health care proxies designated under legal documents.
5
Caregivers who require patient information for medical decisions.
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1
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2
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What are the instructions for submitting this form?
Completed forms should be returned to DUHS Health Information Management via email at ROI-Requestor3@dm.duke.edu, standard mail at DUMC 3016, Durham NC 27710, or fax at 919-384-7148. Ensure that all required documents and identification are attached upon submission. For any inquiries, please contact Duke Medicine Health Information Management at 919-384-7119.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, keep in mind the anniversary of the Proxy relationship creation. If you are using documents like DPOA, be aware that access automatically expires after one year unless renewed. Always check the form for specific dates related to your situation.
What is the purpose of this form?
The purpose of this form is to grant access to a patient's electronic protected health information (ePHI) when the patient is unable to do so due to incapacitation. It serves as a crucial tool for designated individuals, such as legal guardians or family members, to manage health care decisions on behalf of the patient. This ensures that the patient's medical needs are met and decisions can be made promptly and legally.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the incapacitated patient.
- 2. Date of Birth: Patient's date of birth for identification.
- 3. Medical Record #: Unique medical record number assigned to the patient.
- 4. Proxy Name: Full name of the designated Proxy.
- 5. Relationship to Patient: Describe the relationship to the incapacitated individual.
What happens if I fail to submit this form?
Failure to submit this form can delay access to critical health information, hindering timely medical decision-making. It may also complicate the legal standing of the Proxy, leaving the patient without immediate support. Ensure the form is completed and submitted to avoid these issues.
- Delayed Access: Without submission, Proxies may not access necessary medical information.
- Legal Complications: Failure to establish authority can create legal issues regarding decision-making.
- Patient Care Risks: Inaccessibility of health records can jeopardize patient care and treatment.
How do I know when to use this form?
- 1. Incapacitation of the Patient: When a patient can no longer make their own medical decisions.
- 2. Proxy Representation: For individuals authorized to act on behalf of the patient.
- 3. Legal Requirements: To meet legal requirements for accessing a patient’s health information.
Frequently Asked Questions
How do I access the adult proxy form?
You can easily download the adult proxy form directly from our website.
What do I need to submit along with the form?
You'll need to provide legal documents that explain your authority as a Proxy.
Can I edit the PDF after downloading?
Yes, you can edit the PDF using our powerful online editor before submitting.
How long does it take to process the form?
Processing times may vary, but you can typically expect a response within a few days.
What if the patient recovers?
If the patient regains capacity, you should update or revoke the Proxy agreement promptly.
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